30 Chapter 2 groups were comparable. The proportions of agreement for each professional group were slightly higher for intraobserver than for interobserver agreement. DISCUSSION We aimed to study the inter- and intraobserver agreement between and within maternity care professionals (primary care midwives, hospital-based midwives, residents, and obstetricians) in the assessment of aCTG traces among healthy women with an indication for an aCTG (reduced fetal movements, external cephalic version, or postdate pregnancy). The proportions of agreement for interobserver agreement on the classification of aCTG between and within the four professional groups varied from 0.82 to 0.94. The proportions of agreement for each professional group were slightly higher for intraobserver (0.86–0.94) than for interobserver agreement. For the various aCTG components, the proportions of agreement for interobserver agreement varied from 0.64 (presence of contractions) to 0.98 (baseline heart frequency). To the best of our knowledge, the strength of this study is that it is the first to include both primary care midwives and obstetrician-led care professionals (hospitalbased midwives, residents, and obstetricians). For data collection, we used an efficient approach to maximize the number of aCTGs without extra work for the professionals. With at least five assessors per professional group for each set of 10 aCTGs, we guaranteed a reasonable sample of the four professional groups (n = 47). The sample size was large enough to gain sufficient power (20 aCTGs) (see Appendix A1 for sample size considerations).21, 22 However, some limitations need to be addressed. Standard criteria for agreement measures are not available. There are various suggestions in literature on how agreement levels can be labeled, although these guidelines are arbitrary.23, 24 Another limitation is that the participants in our sample, who worked in obstetricianled care, more frequently worked in the same center and region than the participating primary care midwives. The literature shows that professionals working in the same center share similar clinical cultures, which could have influenced the results (observer bias).25 We tried to minimize observer bias (1) by using multiple assessors per professional group, (2) all assessors were trained, and (3) by standardizing our procedure. Furthermore, the risk of observer bias was the same for each group of professionals; therefore, we do not expect this has impacted our results. Despite the fact that aCTGs were sent to the participants via a personal link, there is no absolute guarantee that all aCTG assessments were completed individually.
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